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A nurse navigator-led program at Providence St. Vincent Medical Center in Oregon helped the hospital double its palliative care referral rates for advanced heart failure patients considered to be at high risk of readmission.

This change freed up skilled nursing facilities (SNFs) and home healthcare workers to focus on patients more likely to benefit and recover with care, while increasing utilization of hospice care for declining patients who didn’t want to continue their cycle of hospital readmissions and tests, Margaret Richter, RN, MSN, told Cardiovascular Business. Richter said one of the keys to the program included educating staff members on the benefits of palliative care and helping them gain confidence in broaching the uncomfortable subject with patients and their families.

“I think patients first lack knowledge—knowing there’s another option besides all the tests and procedures and multiple hospitalizations when they aren’t really wanting that but they don’t know how to bring it up,” said Richter, who presented her team’s work last week at the American College of Cardiology’s Cardiovascular Summit in Orlando, Florida.

“It bridges the gap between a patient and their family member because it’s a topic that nobody in the family wants to discuss, so the elephant in the room has shrunk. Patients and families are brought together with a mediator talking about what the patient really wants.”

The program targeted patients who scored a 5 or 6 on the internally developed Providence Vulnerability Index (PVI), which assesses the risk of 30-day readmission by considering a patient’s comorbidities, medical history, behavioral health, history of substance abuse and number of hospitalizations within the past 90 days. A score of 6 is associated with a greater than 40 percent chance of readmission within 30 days, and patients with a PVI of 5 or 6 are generally good candidates for palliative care, Richter said.

In the first phase of the program (June to August of 2017), 25 percent of patients in this category were referred to palliative care. Seven percent of referrals were initiated by Richter as the heart failure nurse navigator, while 18 percent were initiated by providers.

But after the hospital spent a year beefing up its palliative care staff, educating providers on the program and providing scripts to staff members on how to talk about palliative care, the referral rates doubled to 52 percent from July to October of 2018. Richter pointed out the referrals initiated by the nurse navigator (16 percent) and providers (36 percent) both doubled from phase I, representing a true culture shift.

She admitted she grew in her own confidence that palliative care was the right route for many of these patients, which also helped push the program along. Her “sticky notes” in the electronic health record (EHR) were one of the ways in which these consults were facilitated. When an EHR message prompted providers to order a palliative care consult, that result occurred 33 percent of the time. When there was no message, it only happened in 23 percent of cases.

“I had to really put myself out there as a navigator and somebody that was promoting palliative care,” she said. “I used to make notes … saying ‘please consider palliative care’ and now I’m really firm on this is the patient, this is what’s going on, they have multiple comorbid conditions, they have severe heart failure and I put how many times they’ve been in the hospital the last year, and then I recommend (palliative care). I just felt much more confident once I learned more about it to recommend it and talk to more people about it.”

Compared to patients who didn’t have a palliative care consult, those who did were more likely to be discharged to hospice (25 percent vs. 3.8 percent) and less likely to be discharged to a SNF (15 percent vs. 31 percent) or home health (12.5 percent vs. 26 percent).

“The home health nurses, if they’re trying to help people get better and they’re getting a lot of patients where they’re having to navigate a dying situation, that seems obvious that we want the home health nurses with patients that they can actually do something for,” Richter said. “And to get (others) into a hospice situation where the hospice nurses can actually do something for these patients … it just gets them in the right disposition after discharge.”

Richter said other hospitals in the system are considering similar programs after seeing the data from this initiative. Risk assessment tools other than the PVI, which hasn’t been published, could be used if other systems want to use a similar metric in identifying which patients might benefit from palliative care referrals.

One of the barriers to implementation, she said, was hospitalists being hesitant to bring up palliative care because it might lead to long conversations with families and take them away from other duties. The solution was to have them simply order the consult and leave it to the palliative care professionals to go through the options with patients and their families.

“We found that they’re really better at explaining their service than anybody,” Richter said. “I think once the family got to sit down with the parents or whoever it was, they could talk through things—concerns, fears, joys—and they could come together and make a decision.”